Awesome. All right. Thank you. Yeah. Thank you for getting that going. Okay. So we are here to talk about contingency management, which I always joke is not the best name. Nobody likes the name. So please think about what else you might call your program if you are to move forward with this. But basically what contingency management is is positive reinforcement, and it's used to shape behavior and used to reward the behavior that we want to see more of. So it's based in operant conditioning, and it just really encourages positive behavior change. And simply, this looks like receiving a reward or an incentive for providing a negative urine drug test for stimulants. And so that's basically the crux of it. There's a lot that goes into it, and we're going to talk more about it. But that is the underpinning of contingency management. And it's a real celebration of recovery. It really is a positive interaction for both the person delivering contingency management and the person, the relative coming in. And the thing that's important about contingency management, too, is that we currently do not have any FDA-approved medications for stimulant use disorder. And so contingency management is the only available option to effectively treat stimulant use. So there's been decades and decades and decades of clinical trials and evidence in support of contingency management for stimulant use and other drugs that you can monitor over a couple-a-day period. As I mentioned before, we focused on alcohol in our research as well. And due to the increase in stimulant use disorder and poisonings, there's been a real emphasis in rolling contingency management out nationally to address those challenges. And Native communities are disproportionately impacted by stimulant use disorder. And so this is a really great option for folks who are interested in it. And historically, there have been some implementation barriers that we will discuss a little bit today. But those have been addressed in some respects through some states have done Medicaid waivers to provide contingency management as a Medicaid benefit. So that is just a high-level intro to contingency management. And as I mentioned, positive reinforcement is a real key part of what makes contingency management effective. And when we think about positive reinforcement, I think we think of parenting and praising our kids, or we think about gold stars in school. And so these are all examples of contingency management. And the thing that makes this an evidence-based intervention, though, is that it is a treatment that is provided over time. And so we're really thinking about the introduction of a desirable or pleasant stimuli for the performance behavior. So that's really what these psychologists, these behaviorists really focus on, is making sure that we're providing that pleasant reward or incentive for meeting the behavior that we are trying to encourage. And we see that this is effective in really making sure that it happens in the future. And so something that is highly reinforced and consistently positively reinforced will continue to occur. And so that's the other piece of this, is that contingency management is a 12-week program. And so we're encouraging folks over that period to increase their stimulant abstinence. And so we do that through this process. And so one example, our colleagues use a bunch of different simple examples of positive reinforcement. But the one that I always rely on is my love of earrings. And I have quite a collection of earrings, and everybody knows about my obsession. So I'm always getting earrings as presents, and I'm very grateful for that. But when somebody compliments my earrings, I'm more likely to wear the ones that I am complimented for. And so if I were to wear another pair and I don't receive a compliment, then I'm less likely to wear those earrings. So that's an example of reinforcing my earring obsession, is those compliments really help me continue to feel good about those compliments and to then wear them. So that's a very simple example of how positive reinforcement can impact behavior change. So basically, the behavioral principles that underpin contingency management is looking at how we apply positive reinforcement in the project or the program. And this includes the behavior, the reward, and then making sure that you're pairing the two. And so the behavior is focused, it's achievable, it's measurable. And then the reward is tangible, desirable. So it's something that folks really want. And then that they get more of that, the more abstinent they are. So that's what we call escalating. And then we want to make sure that we are pairing the two so that it is contingent, the reward is contingent on providing that you're in negative UDT, that it's immediate. So we make sure that if their urine drug test is negative, that they receive their reward or incentive at that visit. And then again, frequency, we really encourage a program that's two times a week. So folks coming in and receiving those rewards for their abstinence twice weekly. So another thing that we tend to kind of think about is why do people use substances? And we really have come to learn, and I think we all know, is that substance use can be very reinforcing for relatives. And so it becomes an activity that is high on their list and it can start to push out other naturally reinforcing activities because the substance makes you feel good and it removes negative feelings. And so through this process over time, the substance use then changes the reward pathways in our brain. And so despite us wanting to cut down or wanting to not use substances at all, or the negative impacts on our life, our family, our employment, for an example, substance use might continue. And so it can become something that just eclipses everything else in our lives. And stimulant use especially is like this, very potent and can be very reinforcing. And so our colleagues in their trainings usually pose the question about why do people use stimulants and for longer trainings, we have a discussion around the many reasons why people might use stimulants. And I think it's a really good way to think about building empathy, to also sort of push back on the stigma of substance use. But perhaps folks can think to themselves or put in the chat what those reasons might be, why somebody might use stimulants. Some of the reasons that we've heard and come across is that stimulant use can make you feel safe, for an example, if you don't have housing and you are trying to survive outside. It can help you stay up through the night so that you feel safe. It can help address trauma. So if you are feeling those symptoms of trauma, stimulant use can help alleviate that. And so basically, the reason why folks use stimulants falls into two categories. So it makes you feel good and it gets rid of negative feelings. And like we mentioned in the other slide, it does so at the expense of natural reinforcers. So things like family or other externally rewarding activities, it just, they aren't as impactful anymore. So essentially, stimulant use becomes the primary reinforcer in a person's life so that everything is sort of evolving around or revolving around stimulant use. And as we mentioned, there's a lot of reasons why this can occur. But looking at this slide as a decisional balance, we are trying to figure out how do we make stimulant use less reinforcing because it can have all of these positive effects on the left. We need something that is going to outweigh that. And so when we're thinking about that, we're really trying to come up with a way that will encourage somebody to change their behavior. And the thing that is the answer to this is contingency management. And because of the use of positive reinforcement, we are able to help rewire the reward pathway. And even though it sounds very simplistic, it is a very powerful tool to enable folks to jumpstart their abstinence or even reduce their substance use if a harm reduction approach is more within their recovery goals. We do focus on rewarding stimulant abstinence, though, and so that is the focus of the intervention. So, when we're thinking about, you know, how drugs are reinforcing and they change the reward pathway, as I mentioned in the previous slide, we're really needing different tools in our tool belt to really address that. And so contingency management is a opportunity. Our colleagues use the metaphor of a bridge to really help as a pathway or a guide for relatives who are no longer interested in using stimulants or wanting to cut down. And so it's another way of helping them do that. And as I mentioned before, contingency management is a lot of fun, and the folks delivering CM really are able to build relationships with relatives coming in, and the relatives really enjoy contingency management because it is strengths-based, and sometimes folks haven't always had a positive recovery interaction. And so this is one way to help them in a strengths-based approach, and people tend to appreciate that. So the folks who are into it are very grateful for that aspect of really focusing on the positive. So basically, the idea of CM is that people change when they feel good and when they feel positive and when something is bringing them a positive feeling. And so celebration is really interwoven into this work and is really the centerpiece. And thinking about focusing on the behavior that we want to see more of, and so that's the other important piece, is that we're really focusing on the abstinence or the reduction in stimulant use and not focusing on the things that we want to see less of. And so I think that's another piece, is that we are accustomed to really focusing on negative aspects, and so this is an opportunity to sort of flip the approach and really enthusiastically attend to the behaviors that we want to see more of. And so then in this case, of course, that is the return of stimulant-negative urine drug screens. So we also think it's helpful to think about what CM is and isn't. Let's see here. I'll just go ahead and populate it all. So one thing that we do here sometimes is, you know, a CM can be a little bit of a pain sometimes is, you know, CM is just paying people not to use substances, and we really want to push back on the stigma and the stereotyping around that. This is a behavioral therapy, and so it is an effective intervention that is encouraging this behavior change, but again, changing our behavior, any sort of behavior, is really difficult, and even just little things like cutting down coffee or something like that can take a lot of effort, and so when we think about that in relationship to stimulant use, it is a big lift for folks to change that behavior. And so they're not just doing it for a small gift card. You know, they're doing it because they really want to change their lives. They want to repair relationships with family. And so the other piece to this as well is that folks sometimes think that they're doing contingency management when, say, they provide a one-time incentive for a one-time activity. So the one that comes to mind is during COVID when some of our communities received incentives for the vaccine. So that was a one-time or a two-time behavior where they received those incentives. That's not contingency management. Contingency management is this very protocolized approach to having relatives come in twice a week for 12 weeks and only reinforcing abstinence from stimulant use, and so we'll talk about this in some of the slides, but usually those incentives are gift cards that folks are really interested in and excited about, but it could also be culturally meaningful rewards, and so that's another component. It's just really making sure that whatever the incentive or reward is, that that person finds it very valuable to them because that will motivate them to continue to change their behavior. So we have a list on the right here that's talking about what CM is, and so it really helps the relative build confidence. It helps with what in the Western field folks call the therapeutic alliance, so it really builds that relationship between the relative and the staff delivering contingency management. It creates opportunities to celebrate, as I mentioned before, and then it really can help reduce stimulant use or lead to stimulant abstinence. So before we move on to the other piece, I just wanted to see if there was any questions, initial questions, comments. I'm looking at the chat and not seeing anything. Okay. So, as I mentioned, we have been a part of the two clinical trials that were completed with American Indian Alaska Native community partners. And one of them was called the Rewarding Recovery Study, like I mentioned, trying to get away from the contingency management term. And then the other was called Honor, Helping Our Native Ongoing Recovery. And within the Rewarding Recovery Study, we partnered with one rural reservation community in the Northern Plains area. And 114 adults with alcohol use disorder and also they used other substances were randomized. And there was a fancy study design where some relatives received incentives for alcohol abstinence only. Then another group received incentives for abstinence for drugs only. Then there was a third group who received incentives when they were abstinent from both drugs and alcohol. And then what we thought of as our control condition for the group who received incentives for attending study visits. And it was not, they received those incentives that regardless of substance or alcohol use. And we saw a really powerful effect up to eight times the reduction of stimulant use within this work. And we also saw a really big decrease in cannabis use and alcohol. And then the second study, we were focusing on reducing alcohol or increasing alcohol abstinence. And that was a partnership with three communities in both urban and rural areas and one in urban Alaska area. And we had 158 adults with alcohol use disorder who were randomized. And this one was more simplistic. Relatives were either in the group that received incentives for alcohol abstinence, or they were in the group that received incentives for attending study visits and received those incentives regardless of alcohol use. And with this study, we also saw a big reduction in alcohol use and an even larger reduction in cannabis use. Even though people weren't receiving incentives to reduce their cannabis use, that was a secondary impact. And that's the other exciting thing about contingency management is that folks sometimes are worried that focusing on only one substance will lead to increased use in other substances. But the general population literature does not support that. And neither did these two clinical trials. We were really excited to see that there were impacts on other substance use, even when it wasn't the one that was identified for reinforcement. So that's always good to hear that we're getting more impact. So one of the things that we heard was that CM often aligns with cultural values with the various partners that we had in the research, as well with folks that we've been partnering with for training and technical assistance. And what we've heard is that contingency management really, there's a lot of reciprocity, there's a lot of trust that gets established, respect, and it really helps with social support and social connection. And it also aligns with recognizing the individual in the community and encouraging through gifting, which is a value in some of the partnering communities that we have worked with. And so another thing that's a bonus is that gift cards or rewards can be shared with family. And so that's something that has been really meaningful for people to be able to share their success with their family in that way as well. And so one thing that we can pose to you all to think about as we move through the training today is what are other traditional or cultural values that align with CM and which rewards, gift cards, incentives might be the most meaningful in your community and the relatives that you work with. So we have a digital success stories with some of our partners, I guess, probably for the sake of time, I will just go ahead and share this link with folks for you all to check out on your own time if you're interested, but it's a really beautiful example of the impact of contingency management in one rural community. One rural reservation community, I should say. So one of the pieces that we think is super important is thinking about how to make contingency management more culturally responsive and how to really culturally center contingency management. And so there's a lot of different ways that this can be done. So while contingency management is protocolized and it's important to follow the steps that make contingency management effective, there are also opportunities to adapt and be creative. And so again, encouraging you all to think about how that might look in your setting, but we wanted to provide some examples of how this has looked with other communities. And so one way that we've really thought about this is through the concepts of recovery and how we really are thinking about how we describe this within our own community and setting. And so I have another slide that is an example of that, where we were able to map on the CM's visit onto a medicine wheel model and really think about the different domains of the medicine wheel. And so that was one way that an elder was able to really describe the intervention to relatives coming in. And so thinking about how that might look within your own community. Again, the importance of family. I think that this is a value and a strength across Native communities is just how much that's important to our total health and our well-being. And so thinking about ways that family can be welcomed into the program. And so I'm sure that you all have various activities that you do as part of your recovery services with family. So really thinking about connecting that with contingency management as well. Again, the incentives can be another way to really help relatives reconnect with family and build stronger relationships. Sharing worldview and teachings was another example. We've had folks that have had their native language within the visiting room or have had folks that can speak their native language that are able to deliver the intervention. So there's different ways to think about that as well. And then just really ensuring that the staff or the person delivering contingency management are respected community members. As I mentioned before, we had a study where the person delivering contingency management was an elder and that was very impactful for folks. He was able to connect them to culture and cultural resources in a way that other folks wouldn't have been able to. He did impromptu lessons where he would teach them their language or how to put a tipi up or how to collect the different rocks for sweat. So he was really able to provide that cultural connection for folks who were interested in that. So as I mentioned, this was one way that we thought about the contingency management visit using the medicine wheel. But again, encourage folks to think about this in a way that aligns with your community and culture. And so when we're thinking about the medicine wheel, it's all about harmony, balance, and holistic health. And really thinking about the balance of that with the four directions, the four seasons. And in this case, we were able to think about it as the four components of the contingency management visit. And so always starting in the east with greet. And that's really where we build rapport with the relative, checking in on how their day and week has been going, identifying those kinship relationships. And then from there, we move down to measure. And so this is when we collect the urine drug test. We defer to your program policy, but we don't encourage observing the urine drug collection. So we walk the person down to the bathroom and we give them the cup, and then we meet them back in our room where we have our visit. And so that's one thing that we really encourage is a way to destigmatize the use of urine drug screens in the process. And to help folks think about them differently as well as a tool to really tell their story and help us support them in their recovery goals. And so then we move to reinforce. And this is when people are really excited and happy when they've returned a negative urine drug screen. You talk about what they're going to do with their incentive, their plans, what they're excited about and looking forward to. So that's a really important piece to continue to build excitement and elicit that motivation. And then you move to record the outcome. So as I mentioned before, there's been some implementation barriers in the past, despite this being a highly effective intervention. And really, that's because at the heart of the intervention, we are dealing with money. And so we really need to be thoughtful in ensuring that we are providing that incentive for verified abstinence from stimulant use and that that is recorded. So we really encourage robust policy and procedures, tracking sheets for each relative to ensure that we don't get in trouble for Medicaid fraud or anything like that. So Kelsey is going to talk a little bit more about some of the implementation considerations, but that's just certainly something to keep in mind. And then at the heart of it is always gratitude to the relative and acknowledging their recovery goals and being supportive in any way that we can, as we always are. Thinking about whether the person or the relative submits a positive urine drug screen, Kelsey is going to walk us through a way to think about that. But that's an opportunity to connect folks to resources to find out how things are going. We have a really nonjudgmental approach to a positive urine drug screen. And, you know, we just remind folks that they have abstained from stimulants in the past, that they can do it again. And it really provides an opportunity for conversation. The other thing that folks are surprised about with the CM visit is that we it's a pretty brief interaction. And so this could be anywhere from 10 to 15 minutes of a visit. So really pretty short. So other ideas that folks have had about how to help CM be a little more culturally responsive in their community is thinking about where the CM program best fits. And a natural fit, of course, is outpatient treatment recovery or integrated specialty care that has behavioral services and a place that is more accustomed to seeing folks more frequently. So programs that have decided to implement CM in a primary care setting, for example, have some additional barriers to think through for folks because they're not accustomed to coming into primary care twice a week. So that would be another consideration. But that doesn't sound like that's the case here. Another opportunity is for having your program, your CM program located in sort of an unexpected location. So some folks have implemented it within their cultural programming setting, housing, and other areas. Another important thing to think through is barriers related to engagement. And so that will come up a lot. I think folks are surprised that it isn't a factor, recruitment, but it truly is. And so one way that we have seen folks successfully address this is by providing transportation. So that might be something that's already occurring in your program, but certainly extending that to the folks in CM. In larger areas, we've seen that through the form of bus passes or other shuttle rides. So really thinking those aspects through as much as you can ahead of time can be really helpful in the rollout of your program. So as I mentioned, in some of our work, the positive reinforcement has been provided in the native language of the community. It's been about, you know, just as simple as great job, keep it up. Thinking about how that might look within your program as well. We have a picture here from one of our Alaska Native partners, and they were able to write the different words for good job or keep it up in Yupik and Athabascan. So that was really valued by relatives coming in. They also wanted to think about calling their rewards something else. So they called them prizes or rewards. And they really wanted to focus on the recognition piece. And so really recognizing folks that are coming in for their recovery efforts. And this has been identified as a really valuable approach across many of the programs that we have been working with as well. So another piece is thinking about, again, this recognition, this idea and importance of recognition for a relative's efforts in their family, in their community, to be a good relative. And so one thing that was really important to folks was having a participation certification or certificate that folks could have or thinking about having a graduation or engagement party at the end to recognize folks and their time in the program. We also heard that some communities were able to either sing honoring songs or develop a program-specific honoring song that was a part of the recognition of the individual and their time in the program. And this was something that was really valued by relatives. Folks have done blanket ceremonies or feasts in the community. So just thinking about creative ways to really recognize folks is important. So some of the culturally meaningful rewards or incentives focused around, for an example, here's a ton of examples, but here we just have like beading supplies or giving folks beading kits was really valuable. Having medicine bags and medicine kits for folks as well. Again, having events where there's cultural touch points and connections. Thinking about incentives that can be used with families. So going to local restaurants or movie passes when people did that, maybe they're still doing that, was also really popular. But really thinking about what the individual wants and what they'll find the most rewarding is really important. So switching a little bit from incentive ideas to thinking about the program itself. So the program that we support and that is supported by the Tribal Opioid Response Funding is a model of contingency management called voucher-based, essentially. And what that means is that vouchers or a point system is used that equates to a monetary value, like a gift card. In the next slide, I'll have more examples around that. But really that point or that voucher connects to the incentive that's then distributed for that negative urine drug screen and that the relative receives that gift card or that voucher points each time that they do that and really that the exchange is around the voucher for the gift card or the voucher for the reward. So this is a part of the program that you develop, which is thinking about your budget, which Kelsey is going to talk more about. And I think in the next slide, maybe I do as well. But thinking about your budget and how that aligns with your voucher system and making sure that you're able to distribute those gift cards or those incentives. And so one thing that we highlight is the amount that your evidence-based program should be, so the incentive budget essentially. And for that, we really encourage $599 per relative for the 12-week program. And because not everybody will be abstinent all the time, you can usually budget for about half that much. So we really encourage at least a $350 incentive budget per relative. And then I believe Kelsey will speak a little bit more as to why we encourage a $599, at least a $599 or sort of a cap at $599 per participant relative. So here we are listing the important components of rewards and incentives. And so that's that they're tangible, desirable, immediate, and fit your program budget. And at the top, it's talking about the physical gift cards, which is one option, electronic gift cards, another option that we encourage, and then thinking about the culturally meaningful rewards. And so for tangible, those can be really good because they're immediate and the person has it in their hand when they walk out. Electronic gift cards can be less tangible in people's minds. It goes to their email, but it can be easier for tracking. And then culturally meaningful rewards, of course, are great because again, the person is receiving that reinforcement right in the moment. In terms of desirable, physical gift cards can be good. But you do need to think through the different businesses where you'd have gift cards through, you need to make sure that you have enough ahead of time. So there can be some tracking and budgeting considerations there that are less helpful. And so that's why electronic gift cards have a double plus sign, because that makes it especially handy to track and monitor and also distribute in a way that can be monitored. So that makes electronic gift cards more helpful in that respect. Again, thinking about desirable, really want to make sure that we have culturally meaningful rewards available for folks as well that equate to the amount of their earnings for that day. And so that's where that voucher piece would come into play. We also want to make sure, again, that it's immediate. So physical gift cards, sometimes with the budgeting and the amount, depending on the business that you're working with, sometimes you might have like a funky dollar amount that folks have earned. So it might be like $5.25 for that day. But then the business may only have gift cards in $5 increments. And so then that would mean that the relative would have to essentially bank their reward. And so they'd have to wait till the next time when they have an even gift card amount. And so that makes it less immediate. But again, electronic gift cards solve this problem because they usually allow for odd dollar amounts to be dispersed. And then again, the same thing with culturally meaningful rewards, because you're assigning the value to that. Sometimes it can be more flexible. And then of course, program budget, again, the physical gift cards can be tricky because you have to make sure you have enough and of what people want and making sure that you're tracking that. So that can be a little more burdensome than the electronic gift cards. And then the same thing with culturally meaningful rewards, there can be a pro and con depending on how much you're able to spend on community-identified prizes. All right, so I'm just going to go ahead and populate all of this. But to wrap up everything that we were kind of talking about so far is, this slide is an example program, the one that we support. And so it's really breaking down the behavior and the reinforcement. And so again, what you are reinforcing needs to be measurable, and it needs to be defined. And so we have a little star around attainable and focused. So that would be stimulant abstinence is the goal behavior. And then the point of care you're in tests is the way that it's objective and immediate. And then looking at the reinforcement, it's a voucher for gift cards or other culturally meaningful incentives or rewards. And again, with the program, not only are you always thinking about how to make the incentives more desirable and immediate, but you're building upon the abstinence. And so every time a person, every two times a person is abstinent, they get a bonus that escalates for continued abstinence. And then if they have a positive UDT, it starts them back to their base amount of incentives. But then they're able to go back to their original or their previous incentive amount before they had their positive urine drug screen within a week. And so we really just want to continue to encourage folks any way we can to meet their recovery goals. And then, as mentioned here on the bottom right, we're actually looking at a 12-week program where relatives are coming in twice a week. And so thinking about that, and one thing that comes up sometimes is wanting to reinforce other behaviors or thinking about, you know, are urine drug screens really the way to go? And the reason that we really encourage point-of-care tests is that we're not relying on self-report with this. And so there's less opportunity for lack of clarity. And then also point-of-care tests are really great because it observes stimulant use within a point of time that can be really impactful. And so we're getting about three days worth of use with the point-of-care tests. And so that's really beneficial for thinking about these short periods of time for folks to really achieve their abstinence goals. So I don't know if there's any questions or thoughts, but we were just going to wrap up this section by really highlighting that CM is effective for stimulant use with Native communities, that it is flexible in how it can be adapted to fit your program or community. There are ways that CM aligns with cultural values, and that an important feature of this program is to think about how we can address barriers to engagement as much as we can ahead of time. So before I turn it over to Kelsey, I don't know if folks needed or wanted a break, or folks were at, or if there are any questions or comments so far. All right, Kelsey, do you want to share your screen? I guess I had one question. Did you find that the monetary incentives were more highly valued than the cultural incentives that were received? I don't know that I would say, I might say in terms of popularity, gift cards were, I think, preferred, but that was because there was an opportunity for the individual to completely identify where they wanted that gift card and how they'd spend that money. And so that could be purchasing items for their kids or, you know, other needed daily sort of like social determinants of health pieces. But we also want to encourage folks to think about the incentives as something that is fun for them and not just something, you know, that they should use to be, like, we have a colleague who always jokes that, you know, you don't get incentives to get broccoli, right? Like, we don't have to be, you know, this doesn't have to be something where we're, you know, having to be using these resources in a way that's not fun. Like, the point of this is to also have that aspect of it being something that you're finding really meaningful. And so I'd say in that way, the gift cards were more popular, but folks really liked the other, you know, art that was provided or regalia that was provided because that was a way for them to connect with artists in their community. The other thing that they liked about it was that they were able to create their own little, like, side hustles. And so folks who could bead or, you know, could do these other things were then able to sell their items at fairs or at farmers markets. So that was something else that they appreciated. But yeah, that's a great question and something to continue to think about within your own program and what that might look like. Can everyone see that okay? Yeah, looks great. Perfect. All right, so in this next section, we're going to do a very quick high-level overview of some implementation considerations. So thinking about the incentive budget, there are federal anti-kickback safe harbor guidelines around health care incentives, and they suggest that total yearly incentives shouldn't exceed $570. However, there's no actual safe harbor guidelines for CM. Not yet, at least. But research evidence suggests that higher amounts are more effective for CM. So for a 12-week program, we recommend having an incentive budget that's higher than $500 because there's limited evidence for anything less than that. But again, as Kate said, we're not expecting every relative to be completely abstinence-based throughout the entire program. So you can budget estimating spending 50% of the maximum possible earnings. So we recommend a minimum of $350. And I'll get to what we kind of recommend as a max in the next slide. So I'm going to go down to this bullet point. So I'm not, I can't remember if you folks have TOR funding or not, but we get to celebrate that there used to be a $75 limit to incentives for participant relatives. And for anyone involved in CM under TOR funding or SAMHSA funding, it used to be $75 per participant relative. But now you can budget up to $750 per relative annually. However, folks do get taxed on amounts greater than $599. So for our budget, we recommend no less than $350 and no greater than $599 for that incentive budget. And then going to thinking more about sustainability, you can also supplement funds with other types of funding, like tribal funds or opioid settlement funds can be used for those incentives. And I know there is also some staff resistance to the idea of incentives, but again, we really see CM as a tool for recovery and the focus is on helping them either stop using or cut down their using. And there's also been some discussions about harm reduction versus abstinence. It is an abstinence-based program, but really we see CM as a recovery tool that really meets people where they're at. And although they may not be abstinent the entire program, even if they get a negative urine drug screen, like once or twice in the program, maybe that's cutting down for them. And that's something to celebrate. And we still see that as harm reduction because they're using less than they usually would. And a little more about the incentives. We do encourage people to advertise their CM programs, but the thing about that is that you shouldn't advertise it in a way where like, hey, we're giving out incentives for this program, come to our program. You really want to focus on just advertising about CM and don't advertise it in a way that's kind of advertising in a way that's kind of coercing people with the incentives. And next we're moving on to recruitment, which is a really big part of your CM program. So again, you want to identify who the program is for. So we're working with people who use stimulants. And our recommendation is to have a licensed clinician make that referral to the CM program. So you want to have that in their treatment plan just so that, again, you can tie those negative urine drug screens to those incentives just for tracking purposes and avoiding any fraud or things like that. And some strategies are through outreach and education. So you want to build positive connections with tribal leaders, elders, anybody who's skeptical. So hopefully this training and education about the program really helps you to talk to those people and get that buy-in to really start getting people to know your program and get excited about your program. And you want to identify community champions. So as Kate mentioned, the elder in one of the previous clinical trials who would talk to anybody, talk to everybody, provide people with resources. It's great to have someone like that who can talk about your program. And you also want to think about any other community partners that you work with that you can share the program with. And there's also the stigma around urine drug screens, the Department of Corrections and things like that. But with CM, we're turning that punitive testing into positive testing. So instead of viewing those drug screens as something to get people in trouble, it's just really a way for people to share their story and for you as a CM delivery staff and for them as a participant relative to see where they are on their journey. So maybe they got a positive test that day, but that's totally fine. For the delivery staff, your job is to be encouraging. And if they get that positive test, ask them what's been going on, if there's any resources you can point them to, and kind of turn it back to whatever recovery goals they had. Like, hey, remember, you wanted to do this, you're trying to reconnect with your family. Just because you got the positive test today doesn't mean you can't try again next time and get that negative test. And that goes also to the last bullet point of just creating an affirming and supportive dialogue for folks. And some other considerations also to think about in addition to the incentive budget is getting those urine testing materials. So getting those point of care tests, gloves, and any other materials that you'll need for your program, the incentives, and also you want to think about staff time. So depending on your capacity, are you going to hire a new staff? Are you going to have current staff kind of take on multiple hats doing their specific duties that they already have and also helping out with the CM delivery? And you also want to think about space. Do you have a room to have the CM visits? Is there access to a bathroom? Just thinking of different workflow situations like that. And then going further into staffing, these are just some suggested roles that we have come up with with our experience training and doing research with CM. So we have a CM mentor, someone outside the agency that can really help you with your implementation and training. So that's kind of like Kate and I, for example. And then you have your program leads, someone who's been trained in the CM protocol, and they're also responsible for the fidelity of your program, making sure that those results are tied to the incentives, everything's being tracked appropriately. So maybe someone like Mona or Chelsea is what I'm thinking based on our discussions. And then you also have the CM delivery staff. So they'll be your day-to-day people actually working and talking with participant relatives during those visits. They'll be collecting the urine tests, letting people know the results, and distributing those incentives. And this could really, delivery staff could really be anybody as long as they're taught how to appropriately do their visits. So that's something, that's an exciting part about CM, that anybody, anybody could really do it. And then you also have some support staff. They could identify and recruit clients, and also make sure that folks are coming in, reminding them of their next visits. And again, this is all, this is all based on your capacity and staff time. So some people could wear multiple hats, or you can have separate staff for CM. And then any questions about those considerations before we move to an activity? RF Kate, I don't know if you wanted to add anything. Yeah, I think that was helpful. One of the things we do encourage is having at least two delivery staff, part-time or full-time, just so that you always have coverage for stuff that comes up. So that's one implementation piece that we've observed that can really help with workflow. Okay, yeah, I don't see any questions in the chat, so we'll go ahead and move on. All right, so for our activity, we kind of wanted to get folks thinking about what they would do in case someone had a positive urine drug screen. So just thinking about what might they be feeling, and what have you heard, or what might you hear from people. Sometimes people get those positive tests, and they, you know, they swear like they didn't use before. You'll get, you'll hear that a lot. But to maintain fidelity to the program, and to really stay evidence-based, we want to reward them for the right behavior. So we can't give them that incentive or that reward at that time. And sometimes there's been instances where, you know, folks are frustrated, they're not doing so great, and sometimes there's been staff who will feel bad and give them the gift card. But we really can't do that, and we just really want to make sure that that incentive is tied to the negative urine drug screen. So next we have an example, just kind of like a brief little dialogue of what people could say during a positive urine drug screen. So again, remember that's the time where you want to encourage them, be non-judgmental, think about other resources you could offer, and reminding them of the recovery goals. So for the next five minutes, we're gonna go ahead and split up into breakout rooms. So we're gonna go ahead and practice, one person will be the CM delivery staff, the other person will be the participant relative, and that participant relative got a positive urine drug screen, so they won't get that reward or incentive. So we want the delivery staff person to kind of practice how they would talk to the participant relative who got their positive urine drug screen. I want to share what they talked about in their breakout room, or what strategies they used to discuss. We talked about how it's kind of situational, depending on who the person is, whether you're related to them, whether their background, their history with the program. All of that kind of takes, you have to take all of that into account when you're going to address somebody. But I mean, overall, just keeping a positive outlook on it, and being encouraging, and not letting one little bump in the road throw them off from their journey and their progress, and just encourage next time. It's OK. It happens. But just keeping positive with them. Yeah. Thank you for sharing. And that's really important. I like that you brought up that it's situational, and it depends on the person that you're working with. Anyone else want to share? Maybe one more person before we start wrapping things up. Oh, yeah. This is Crystal. Anthony was in our group, and Kirsten doesn't have a mic. But kind of the same line is that even if they had tested positive, and just encourage them to keep coming back, and that the program's going to work for them, and encourage, give them pats on the back. You can do it. And then I got called for a random, so I got to leave here pretty soon. Real crazy. Just because we're talking about urine tests, and I got to go do one pretty soon. Thank you, Amanda and Crystal, for sharing from your groups. And yeah, we appreciate that you guys took the time to do this. And I also like that you brought up recognizing folks, and giving them that encouragement. Yes. Thank you so much. That was really great to hear. So do we have any questions or final thoughts? Otherwise, thank you so much, everyone, for joining us today. And it was really great to hear all of your experience, and thoughts, and wisdom. So we appreciate it.

contingency management

positive reinforcement

stimulant use disorders

operant conditioning

abstinence

Native communities

empirical support

cultural values

reward pathways

family support

implementation challenges